This document provides guidelines for airway management, chest trauma management, hemorrhage control, circulatory access, fluid resuscitation, heat preservation, pain management, documentation, and training for pre-hospital trauma care. Key recommendations include performing rapid sequence intubation within 45 minutes, using tourniquets and pelvic binders for bleeding, intraosseous access if IV fails, restrictive fluid resuscitation, recording injuries and treatments, and ensuring ongoing training for all trauma clinicians. The guidelines aim to optimize trauma patient care and outcomes in pre-hospital settings.

1. 2016 NICE MAJORTRAUMA
ASSESSMENT AND INITIAL
MANAGEMENT
PRE-HOSPITAL RECOMMENDATIONS
Excerpt From: NICE. “Major trauma: assessment and initial
management.”

2. AIRWAY MANAGEMENT
IN PRE-HOSPITAL
SETTING

3. Airway management in pre-hospital
setting
■ Aim to perform RSI as soon as possible and within 45 minutes of the initial call to the
emergency services, preferably at the scene of the incident.
■ If RSI cannot be performed at the scene:
– consider using
1. a supraglottic device if the patient's airway reflexes are absent
2. basic airway maneuvers and adjuncts if the patient's airway reflexes are
present or supraglottic device placement is not possible
– transport the patient
1. to a major trauma center for RSI if the journey time is 60 minutes or less
2. to a trauma unit for RSI before onward transfer if a patent airway cannot be
maintained or the journey time to a major trauma center is more than 60
minutes

4. MANAGEMENT OF CHEST
TRAUMA IN
PRE-HOSPITAL SETTINGS

5. Management of chest trauma in
pre-hospital settings
■ Use clinical assessment to diagnose pneumothorax for the
purpose of triage or intervention.
■ Consider using eFAST (extended focused assessment with
sonography for trauma) to augment clinical assessment only
if a specialist team equipped with ultrasound is immediately
available and onward transfer will not be delayed.
■ Be aware that a negative eFAST of the chest does not exclude
a pneumothorax.

6. Management of chest trauma in
pre-hospital settings
■ Only perform chest decompression in a patient with suspected tension
pneumothorax if there is haemodynamic instability or severe respiratory
compromise.
■ Use open thoracostomy instead of needle decompression if the expertise is
available, followed by a chest drain via the thoracostomy in patients who are
breathing spontaneously.
■ Observe patients after chest decompression for signs of recurrence of the
tension pneumothorax.
■ In patients with an open pneumothorax
1. cover the open pneumothorax with a simple occlusive dressing
2. observe for the development of a tension pneumothorax.

7. MANAGEMENT OF
HAEMORRHAGE IN
PRE-HOSPITAL SETTINGS

8. Management of haemorrhage in
pre-hospital and hospital settings
■ Dressings and tourniquets in pre-hospital and hospital
settings
1. Use simple dressings with direct pressure to control
external haemorrhage.
2. In patients with major limb trauma use a tourniquet
if direct pressure has failed to control
life-threatening haemorrhage.

9. Management of haemorrhage in
pre-hospital and hospital settings
■ Pelvic binders in pre-hospital settings
1. If active bleeding is suspected from a pelvic fracture
after blunt high-energy trauma
■ apply a purpose-made pelvic binder
■ consider an improvised pelvic binder, but only if a
purpose-made binder does not fit.

10. Management of haemorrhage in
pre-hospital and hospital settings
■ Haemostatic agents in pre-hospital and hospital settings
1. Use intravenous tranexamic acid as soon as possible
in patients with major trauma and active or
suspected active bleeding.
2. Do not use intravenous tranexamic acid more than 3
hours after injury in patients with major trauma unless
there is evidence of hyperfibrinolysis.

11. CIRCULATORY ACCESS IN
PRE-HOSPITAL SETTINGS

12. Circulatory access in pre-hospital
settings
■ For circulatory access in patients with major trauma in
pre-hospital settings:
1. use peripheral intravenous access
2. if peripheral intravenous access fails, consider intra-osseous
access.
■ For circulatory access in children (under 16s) with major trauma
1. consider intra-osseous access as first-line access if peripheral
access is anticipated to be difficult.

13. VOLUME RESUSCITATION
IN PRE-HOSPITAL
SETTINGS

14. Volume resuscitation in pre-hospital and
hospital settings
■ For patients with active bleeding use a restrictive approach to volume
resuscitation until definitive early control of bleeding has been achieved.
■ In pre-hospital settings, titrate volume resuscitation to maintain a palpable
central pulse (carotid or femoral).
■ For patients who have haemorrhagic shock and a traumatic brain injury:
1. if haemorrhagic shock is the dominant condition, continue restrictive
volume resuscitation
2. if traumatic brain injury is the dominant condition, use a less restrictive
volume resuscitation approach to maintain cerebral perfusion.

15. FLUID REPLACEMENT IN
PRE-HOSPITAL SETTINGS

16. Fluid replacement in pre-hospital setting
■ In pre-hospital settings only use crystalloids to replace fluid
volume in patients with active bleeding if blood components
are not available.

17. REDUCING HEAT LOSS IN
PRE-HOSPITAL AND
HOSPITAL SETTINGS

18. Reducing heat loss in pre-hospital settings
■ Minimise ongoing heat loss in patients with
major trauma.

19. PAIN MANAGEMENT IN
PRE-HOSPITAL AND
HOSPITAL SETTINGS

20. Pain management in pre-hospital and
hospital settings
■ PainAssessment
1. Assess pain regularly in patients with major trauma using a pain assessment
scale suitable for the patient's age, developmental stage and cognitive function.
■ Pain relief
1. For patients with major trauma, use intravenous morphine as the first-line
analgesic and adjust the dose as needed to achieve adequate pain relief.
2. If intravenous access has not been established, consider the intranasal route for
atomised delivery of diamorphine or ketamine.
3. Consider ketamine in analgesic doses as a second-line agent.

21. DOCUMENTATION IN
PRE-HOSPITAL SETTINGS

22. Documentation in pre-hospital settings
■ Recording information in pre-hospital settings
1. Record the following in patients with major trauma in pre-hospital settings:
■ catastrophic haemorrhage
■ airway with in line spinal immobilisation
■ Breathing
■ Circulation
■ disability (neurological)
■ exposure and environment
2. If possible, record information on whether the assessments show that the patient's
condition is improving or deteriorating.
3. Record pre-alert information using a structured system and include all of the following

23. Documentation in pre-hospital settings
– Record pre-alert information using a structured system and include all of the
following
■ the patient's age and sex
■ time of incident
■ mechanism of injury
■ injuries suspected
■ signs, including vital signs and Glasgow Coma Scale
■ treatment so far
■ estimated time of arrival at emergency department
special requirements
■ the ambulance call sign, name of the person taking the call and time of call.

24. TRAINING AND SKILLS

25. Training and skills
■ Recommendations for ambulance and hospital trust boards, medical directors and senior managers
within trauma networks
1. Ensure that each healthcare professional within the trauma service has the training and skills to
deliver, safely and effectively, the interventions they are required to give, in line with this guideline
2. Enable each healthcare professional who delivers care to patients with trauma to have up-to-date
training in the interventions they are required to give.
3. Provide education and training courses for healthcare professionals who deliver care to children
with major trauma that include the following components:
■ safeguarding
■ taking into account the radiation risk of CT to children when discussing imaging for them
the importance of the major trauma team, the roles of team members and the team leader, and
working effectively in a major trauma team
■ managing the distress families and carers may experience and breaking bad news
■ the importance of clinical audit and case review.”